Every finding on record at Desert Ridge Transitional Care Center, LP

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 3) sampled for gastrostomy tube (G-tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and/or medications), received physician ordered care when there was no documented evidence to indicate staff cleaned the Resident 3's G-tube site and performed daily dressing changes on December 27, 2025, January 1, 2026, and January 3, 2026.This failure had the potential to place Resident 3 at increased risk for infection and compromised skin integrity.Findings: A review of Resident 3's admission Record (contains medical and demographic information), the admission Record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (paralysis and weakness to one side of the body) affecting left non-dominant side, epilepsy (a condition marked by recurrent seizures), dementia (a syndrome marked by a decline in cognitive functions including memory, language, reasoning, and judgment, severe enough to impair daily life and independence), and encounter for attention to gastrostomy (care specifically focused on the management, or maintenance of an existing gastrostomy tube).During a review of Resident 3's care plan (an individualized plan for the medical care of a resident) titled, Excoriation of gastrostomy (GT).site: Resident has risk for skin impairment at GT.site. dated December 15, 2025, the care plan included interventions which indicated, .Provide protective skin care. - Treatment as ordered.During a review of Resident 3's care plan titled, At risk for infection - GT: resident is at risk for infection due to gastrostomy tube (GT) site. Dated December 15, 2025, the care plan included interventions which indicated, GT care daily and assess for redness, pain, swelling, increased temp and discharges and report to MD promptly.-Keep skin clean and dry.-Treatment as ordered.During a review of Resident 3's physician's orders, an order dated December 15, 2025, indicated, [Treatment] GT site: Cleanse with NS [normal saline- a sterile saltwater solution with the same salt concentration as human blood, used medically for wound cleaning], pat dry, apply T-drain dressing [a type of gauze dressing] every day shift for wound mgmt [management].During a review of Resident 3's Treatment Administration Record (TAR - a document used to record treatments provided to the resident) dated January 1, 2026, through January 31, 2026, the TAR indicated the task, GT site: cleanse with NS, pat dry, apply T-drain dressing every day shift for wound mgmt. The TAR task was blank with no documentation by staff to indicate the task was performed on January 1, 2026, and January 3, 2026.During a review of Resident 3's Treatment Administration Record (TAR), dated December 1, 2025, through December 31, 2025, the TAR indicated the task, GT site: cleanse with NS [normal saline - a sterile solution of sodium chloride in water, commonly used for wound irrigation and cleaning], pat dry, apply T-drain dressing every day shift for wound mgmt. The TAR task was blank with no documentation by staff to indicate the task was performed on December 27, 2025.During a concurrent interview and record review on January 8, 2026, at 9:45 AM, with the Director of Nursing (DON), Resident 3's TARs dated December 1, through December 31, 2025, and January 1, through January 31, 2026, were reviewed. The DON stated Resident 3 was supposed to have her G-tube site cleaned with NS, patted dry, and a T-drain dressing applied daily and the nursing staff were supposed to document completion of the task on the TAR. The DON acknowledged there were 3 days (December 27, 2025; January 1, and January 3, 2026) with no documentation to indicate the task was completed. The DON stated the task was supposed to have been completed and he did not know why it was not. The DON further stated it was important that physician's orders were followed and carried out. The DON stated the importance of cleansing the g-tube site and applying a new dressing daily was to ensure there were no complications with the site and to prevent infection.During an interview on January 8, 2026, at 3:43 PM, with the Infection Preventionist (IP), the IP stated the task of cleansing of the G-tube site and placing a new T-drain dressing daily was important for infection prevention.During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding - Site Care, Revised March 2023, the P&P indicated, The purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection.1. Review the physician order including necessary supplies for cleaning the enteral feeding tube site.4. Licensed staff will gently clean the area immediately surrounding the tube and continue working outward in a circular motion.8. Evaluate the stoma site [surgically created opening where the g-tube inserts into the abdomen] for signs of redness, pain or soreness, swelling, or drainage.